1 / 27

A day (and night) in the life of…

A day (and night) in the life of…. Surviving the job. Constantinos Papoutsos Tharaka Chandrakumar FY1 Manchester Royal Infirmary. Overview. The ward round The jobs The oncall Common calls Handover. Carrying Stuff. Clipboard Spare cont sheets, referral forms,

cheng
Download Presentation

A day (and night) in the life of…

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A day (and night) in the life of… Surviving the job Constantinos Papoutsos Tharaka Chandrakumar FY1 Manchester Royal Infirmary

  2. Overview • The ward round • The jobs • The oncall • Common calls • Handover

  3. Carrying Stuff • Clipboard • Spare cont sheets, referral forms, • Protocols eg ACS, COPD, DVT • Useful numbers • Invx depts ego USS, vascular lab, CT • Wards • Secretary/ dept fax nos • Anticoag • On call bleeps • WATER + SUGAR • Pocket prescriber / oxford handbook

  4. Ward round • Preparing • Blood book • Blood forms for phlaebos • SOAP • Subjective: symptoms • Objective: Signs/ OE, Obs/ Bloods • Assessment: Impression • Plan • CLARIFY QUERIES

  5. And now to work… • UNWELL • Urgent invx, chase • COFFEE • TTO • Referrals • Bloods • Try get learning experiences • Audit, DOPS, Mini-CEX

  6. Before… • Prepare: • Likely clinical problems: SOB, Chest pain, Hypo/hypertension, Hyperglycaemia, Confusion/Agitation, Pyrexia • BUT you need to know: • When/where is handover? • Key codes for locked doors • Bleep policy (H@N or direct) • Seniors’ bleep numbers • Clinical support available?

  7. During Nights • Prioritise • Elective admission clerking Vs EWS: 5 • Ask for help • Dangerous not to • NS as well as seniors • Assert yourself when people are unwilling. • Breaks + Naps • Drink + 20min rest can be restorative

  8. During… • Eat and Drink • Similar eating pattern to day shifts • Double-check • Is it Tazocin 4.5g or mg? • Avoid temptation of caffeine • 3a.m. – 6a.m. is circadian nadir • Also right before you want to sleep • Avoid the dark • Light helps keep you alert

  9. EWS • Early Warning Scores ≥3 prompt Med R/v • Early detection of the unwell pt • Always ask what pt is scoring on + Sats • What have prev scores been • Trends more useful than one-off scores • Quick PMHx from NS • Lots can be done whilst you’re on your way • BM/O2/ECG/Flush catheter/Cannulate • Use scores to prioritise pts • EWS ≥ 5 = SpR • EWS ≥ 7 = Consultant

  10. Elective Clerking • Usually pre-op done • But should not really say • Seen in pre-op, no changes… • At least ensure ROS • PMH • Examine i.e murmurs, AF? • Up to date drug list • Ensure G&S, clotting

  11. Fluids • Always check U+E • Na + K in particular • Order U+Es if no recent results • Don’t blindly px for 24hrs • If asked for just fluids for low bp • Ideally assess the px, u.o important. • Check clinical notes • Still for IVF? • Pt diabetic/Liver failure? • Any Sepsis/CCF/LVF? • Is pt E+D?

  12. Analgesia • Over the phone: • Obs/EWS? • Any PRN? • Don’t be stingy • Unfair on pt • More work for you • Don’t blindly Rx • Why in pain? • Check Kardex for PRN • Given? • Need some PMHx • Admitted w/ Crohns now has shoulder tip pain!

  13. BMs • High • Over the phone: • Pt AVPU/Obs/Abdo pain/Vomiting • NS for a rpt + urinalysis (Lab glucose if poss) • Cld it be from a drip arm? • Be polite when asking! • Pt on steroids? • Pt Type II diabetic? • Prob has BM > 11 at Home

  14. BMs • At the ward: • See pt! • DKA = ABG + Immediate treatment • Not DKA + glucose > 22 = Actrapid • Check Kardex • Drugs given/on time • Check BM chart • Pattern of elevation? • Type II diabetic: increase PO hypoglycaemic • Suggest DM specialist nurse r/v • Consider sliding scale if acute illness

  15. BMs • Low • Over the phone: • Pt AVPU/Obs • NS to rpt (Lab glucose if poss) • At the ward: See pt • If alert/well rpt BM + give sweet drink/biscuit • If cannot drink/unresponsive give Dex IV STAT + Glucagon IM/SC • Check Kardex + adjust as necessary • Rpt BMs 1hrly till stable • If o/d on LA insulin/PO hypoglycaemics may need Dex drip for up to 48hours • Adjust rate to BMs • NEVER OMIT LONG ACTING INSULIN!

  16. Confusion • Consider underlying causes • Always ask hx • r/o head injury • Don’t just write sedation • Septic screen

  17. Falls • On the phone: • Any witnesses • Pt Obs stable/actively bleeding/obv #s? • At the ward: • Hx from pt • Obs/GCS/MMSE • Examine for cuts/bruises/bleeding/#s • Hip, wrist + scaphoid, skull • Head injury/drowsiness consider CT • Kardex • Consider FBC, MSSU, U+Es, ECG

  18. Falls • Complete accident form • Document • Ask NS for reg Obs • To bleep if concerned • Consider why • Bed too high, visual problems, unaware of buzzer, post-sedation/anaesthetic. • TIA, arrhythmia, postural hypotension.

  19. Sedation • On the phone: • Why sedation requested • PMHx from NS • Night sedation • Dose reg meds to aid sleep • Sleep hygiene • Zopiclone (3.75-7.5mg/24hr) • Emergency sedation • Lorazepam (1-2mg, PO/IM/IV stat) • Haloperidol (2-4mg, PO/IM/IV stat) • Don’t get cornered

  20. Nausea • On the phone: • Obs/EWS • Any vomiting, abdo pain, diarrhoea, headache • At the ward: • Hx + examination • Kardex – any new drugs? • If had N+V previously ask pt what worked • Cyclizine covers most causes • PRN

  21. Potassium • High K+: • If sudden & unexpected rpt sample, do ECG • ?Haemolysed • If confirmed: • Salbutamol nebs/Insulin act in the short-term • Calcium gluconate protects cardiac muscle • Calcium resonium/Dialysis cause excretion of K+ • Investigate why • Diuretics/ACEi/Renal Failure

  22. Potassium • Low K+: • Common in Nausea, Vomiting andDiarrhoea pts • ECG + examination rarely necessary • Sando K for 3 days, then rpt U+Es • 20-40mmol K+ IV added to IV fluids

  23. Death • 5 signs: • No reaction to voice or pain • Sternal rub/Supraorbital pressure) • No pupillary reflexes • Pupils fixed and dilated, eyes dry • No central pulse • Femoral/Carotid for minimum 1 min • No breath sounds • Listen for minimum 1 min • No heart sounds • Listen for minimum 1 min • Record examination & time in the notes (RIP) • Record if Pacemaker in situ • Feel chest • Check recent ECG • Look at recent CXR • Browse through clinical notes

  24. Referring • Always get advice from your SHO for your patients initially • Other specialties: Med Reg (3501), Cardio Reg (4004), RSO (SHO) 8000/8001 • SBAR

  25. Handover • Giving: • Which pt and where they are • Brief management summary + outstanding jobs • Likely complications/difficulties + plan • SBAR • Receiving: • Make sure you understand • Document • Who, Where, Why, What?

  26. Cliché Time Look after yourselves!! And each other… You are not alone Just do it!

  27. Questions • Thank you • Acknowledgment: Kind thanks to Laura Cooper (FY1) who contributed the bulk of this presentation

More Related